The Quality Cost Connection

Don’t let impairments jeopardize patient safety

Separate health matters from discipline

By Patrice Spath, RHIT

Brown-Spath & Associates

Forest Grove, OR

Recognizing and effectively responding to impaired physicians is a critical component of a hospital’s patient safety initiative. The Joint Commission on Accreditation of Healthcare Organizations has an explicit requirement that the hospital medical staff have a process to identify and manage matters related to individual physician health (MS.2.6).

This process should be separate from the medical staff disciplinary function. Traditional medical staff bylaws have contained no provision for modifying behavior, only for punishing behavior. Generally, the only actions provided for in the medical staff bylaws are: corrective action, summary suspension, automatic suspension, automatic termination, and due process.

The purpose for separating health matters from disciplinary matters is to encourage the implementation of a process that will not damage the physician’s reputation as a result of impairment. The goal is to identify health-related problems at an early stage, put supportive services in place, and implement necessary safeguards to protect the safety of patients while (if possible) allowing the physician to remain in practice.

The Joint Commission standards do not define what is meant by "health-related problems." However, many facilities use the Chicago-based American Medical Association (AMA) definition of impairment: The inability to practice medicine with reasonable skill and safety to the patient by reason of physical or mental illness or alcoholism or drug dependency.

Staff member education about the warning signs of physician impairment and how to report suspected problems is an important step toward minimizing patient safety problems.

Physicians and staff members should be educated about the signs/symptoms of a health-impaired physician. The AMA statement about impaired physicians can be used as a basis for this education.

According to the AMA, evidence of impairment includes observation of slurred speech, confusion, unsteady gait, tremulousness, failure to answer pages, and the perception of an odor of alcohol or alcohol on the breath.

Objective evidence of consumption is the presence of any alcohol in the blood and/or a positive qualitative urine drug screen. There are other, more subtle signs to watch for: outbursts of anger, a disorganized schedule, patient or staff complaints, unexplained absences or inaccessibility, and other inappropriate or unpredictable behavior.

A question that often comes up during discussions of physician impairment is, "What about the disruptive physician?" Repeated loud yelling or other verbal abuse directed toward patients, visitors, hospital staff members, or other physicians should not be tolerated. The recent Institute of Medicine report, To Err is Human, described the importance of teamwork and free exchange of ideas among members of the health care team.

Any member of the team who is disruptive will have a damaging effect on collaboration. If everyone is afraid to talk to the physician for fear of being verbally abused, there is a significant potential for patient harm.

The medical staff should have a definition of what is meant by "disruptive." The AMA definition might serve as a starting point: A style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care.

The key phrase is "style of interaction" — a physician who has a one-time outburst of anger, but who is generally easy to work with, would not be labeled disruptive. To be considered disruptive, a physician would exhibit a pattern of repeated inappropriate verbal acts that have the potential for decreasing the quality of patient care.

Of course, if a physician commits one act of physical abuse toward any person, the medical staff should take immediate action.

A pattern of disruptive behavior or a sudden change in a physician’s ability to work well with other team members is a sign of possible impairment. For this reason, staff members should be encouraged to report such behaviors. There may be physical as well as mental causes for the behaviors or substance abuse concerns. In these circumstances, the medical staff impaired physician policy would apply.

Notification and action

The organization should have a formal notification process that physicians and other staff members are encouraged to use for reporting suspicious behavior problems. Everyone should be made aware of this process. Many hospitals allow for an oral report of concerns if the problem requires immediate attention.

This report can be directed to the chief executive officer, the chief of staff, or their designee. Don’t require that the person making the report have absolute proof of the physician’s impairment; however, he or she should be encouraged to state the facts that caused suspicions and any collaborating opinions from other people who observed the incident.

There should be a mechanism by which physicians suspected of health-related problems are referred to a medical staff committee or other group for further investigation. This process should include an objective evaluation of the credibility of the allegation. The impaired physician policy should include a procedure for immediate action when hospital team members, a patient, or a patient’s family expresses concern that a physician appears acutely impaired. The ranking nurse manager on duty or hospital administrator should be involved in these situations, ideally in consultation with a member of the medical staff executive committee. If warranted, immediate coverage should be arranged for the physician’s patient(s) and appropriate testing done (e.g., urine drug screen and blood alcohol). Label laboratory specimens as "John Doe" or another alias to protect the confidentiality of the affected individual.

Disruptive behavior may fall under the professional conduct policy of the medical staff. There should be a provision allowing the physician’s medical staff membership and/or privileges to be reduced or revoked if the disruptive behavior adversely impacts the ability of the health care team to provide quality patient care. By linking the unacceptable behavior to quality of care, courts generally will uphold the medical staff’s decision if the physician in question chooses to sue the medical staff. Because disruptive behavior is a complex problem, the traditional peer review process investigation may not be appropriate; however, if changes in the physician’s privileges or medical staff membership are contemplated, all aspects of due process should be followed.

If the physician is suspected of having health-related problems, it is important that supportive actions are undertaken by the medical staff. This includes referral to outside organizations that can provide diagnosis, treatment, and rehabilitation services. Most state medical associations offer "Impaired Physician" assistance.

If treatment is recommended by the outside organization, the hospital medical staff may ask for periodic reports of the individual’s progress, including compliance with the treatment and rehabilitation plan.

If the physician continues to care for patients at the hospital while undergoing treatment for the health problem, the medical staff must have stringent ongoing monitoring of the individual’s performance to protect the safety of patients. If it is determined that the physician is unable to practice safely, the peer review mechanism detailed in the medical staff bylaws would be triggered.

Many hospitals ask impaired physicians to voluntarily request a medical leave of absence and stop seeing hospital patients while under active treatment. If the physician refuses to discontinue practice voluntarily, the physician’s privileges are immediately suspended until treatment has concluded.